The 42 participants of the PBF course.

The 93^rd international FBP course, the first course of which started in 2007, was held from April 29 to May 11, 2024, at the Atlantic Beach Hotel in Cotonou bringing together 42 participants from three countries.

Hereby the course report. (rapport)

The next PBF course in Lomé (Togo) will be organized from January 13th until the 25th 2025. Hereby the announcement (annonce).

This international course demonstrates that there is again a growing demand for skills building in international PBF and for other continuing courses organized at the national level. The successes recorded as part of the PBF reforms in the countries concerned, particularly in Mali, have made it possible to improve the quality of services and increase the main indicators of service provision. In addition, staff motivation and retention, particularly in rural areas, have improved.

This gives hope that PBF is the essential approach to achieve Universal Health Coverage.

The positive results of the PBF reforms in Mali, which correctly applies best practices and instruments, show that combining direct financial support based on performance with autonomous management of health facilities is the solution for efficient and high-quality health services, at primary, secondary and tertiary levels.

PBF is also believed to be experiencing a revival in several countries after the slowdown caused by COVID-19. This includes the potential of PBF to improve the efficiency of tertiary hospitals which often experience terrible inefficiency in the use of state resources, and which often results in an unregulated privatization through informal services provided by government health workers.

In addition, the PBF addresses the problem of shortage of qualified health personnel in remote and war-affected areas. This effectiveness of the PBF in stabilizing the health sectors (and potentially also education and other sectors) contributes to reducing social tensions. For future compulsory insurance systems, we believe that PBF could also solve the challenges of quality control, strict verification and cost control. The creation of contracting and verification agencies under the aegis of the CANAM compulsory insurance system in Mali shows good prospects.

Mali

Health system problems in Mali

Decades of implementation of several reforms have not significantly improved impact indicators such as crude mortality, maternal mortality and infant and child mortality.

There is an insufficiency in health personnel and an inadequacy in the geographical distribution of human resources. The performance of the national public pharmaceutical supply system is suboptimal. Prepayment systems are still fragmented and only cover around 13% of the population.

This situation is aggravated by the multidimensional crisis with persistent insecurity making it difficult to focus on health services in the northern and central parts certain of the country.

Performance-based financing (PBF) in Mali

To deal with these problems, Mali is committed to implementing the PBF reforms, which underwent two pilot phases in the Koulikoro region. The budget planned for the component “Strengthening Health Service Delivery (RPSS) 2000-2024 through performance-based financing” is USD 66.4 million (IDA USD 34 million and USD 3 million from the GFF and USD 29.4 million US of the Netherlands).

Recommendations from the Mali course participants (and who)

A new phase of the FBP will begin in October 2024 and there is a need for intense advocacy to the authorities and its partners to continue with the PBF reforms as a preferred health reform strategy.

The following specific recommendations are proposed:

1. Adopt the institutional reforms required to integrate the PBF approach in the health sector and other sectors at parliament level.
2. Apply the conclusions and recommendations that will result from the work of the Technical Committee of Experts of the Ministries of Economy and Finance and the Ministry of Health and Social Development responsible for examining the modalities for operationalizing performance-based financing in the State Budget (at Ministry of Finance- and Health level)
3. Insert a PBF budget line in the budget of the Ministry of Health and Social Development (at Ministry of Finance- and Health level)
4. Implement the manual for mobilizing and executing financial resources in PBF mode (currently being developed) and revise certain existing texts (Ministry of Finance).
5. Establish a State PBF support fund at the national level for sustainability (Ministry of Finance).
6. Advocate to the State and Partners to apply PBF or some practical PBF tools and instruments in the regions of Sikasso, Timbuktu and the District of Bamako (Regional Health Directorates).
7. Put national ministry of health directorates under performance contract for the sustainability of the achievements of the PBF Approach (National PBF Unit)
8. Frequently transfer the district verification officers of the Contract Development and Verification (CDV) Agencies to avoid collusion (CDV Agencies and PBF Unit)
9. Reduce the number of output indicators to simplify the quantity verification process by the CDV Agencies and reduce the verification of quality elements during the quantity verification. Quality verification is a task of the district health authorities. The objective is to be realistic with how much work medical verification officers can do within a 3–4-hour visit (National PBF Unit, CANAM).
10. Set up an output indicator that can ensure the referral of patients, and in particular for vulnerable patients (National PBF Unit).
11. Sign bipartite contracts between a. The in-charge of the community health centers and the CDV Agency; b. The manager CSREF and the CDV Agency) instead of tripartite ones (National PBF Unit).
12. Sign bipartite contracts between ASACO and the in-charge of the CSCOM to ensure community involvement. ASACO can recruit the in-charge of the CSCOM, supervise the CSCOM, but should not be involved in the daily management of the CSCOM (National PBF Unit).
13. Develop service/performance contracts between the municipalities and the CSRéf Manager only after an in-depth analysis and a clear definition of the roles and responsibilities of both parties (National PBF Unit).
14. Liberalize the supply and distribution of inputs (medicines) and allow health facilities to obtain supplies from the best supplier/wholesaler operating in competition but which are accredited by the government (National PBF Unit).
15. Advocate to government and partners for the implementation of PBF in tertiary hospitals and the development of exemptions for feasibility (Tertiary Hospitals Directors)
16. Make exceptions to apply best practices and PBF instruments by tertiary national hospitals with technical support from experts of the World Bank
17. Transform state subsidies for hospitals from existing budget lines into FBP budget lines (Ministry of Finance- and Health)

The Union of the Comoros – context and recommendations

A PBF project was set up in 2011 with support from the French Development Agency (AFD). The COMPASS project took over in June 2021 with support from the World Bank. These two PBF projects have shown promising results.

However, the PBF feasibility analysis, conducted by the participants from the Comoros applying 23 criteria, found a score of 20 out of 50, or 40%. This is well below the minimum standard of 80%, necessary to correctly operate the FBP reforms.

For this, the following recommendations are proposed:

1. Map all health facilities (public and private) and rationalize the health facilities into primary level catchment areas (minimum package of activities) of between 4000 and 12.000 inhabitants and hospital level catchment areas (complementary package of activities) of at least 50.000 inhabitants.
2. Promote fair competition between accredited distributors through the liberalization of the input supplies, including medicines.
3. Grant more autonomy to health facility managers.
4. Separate the functions of the CDV Agency and the payment agency.
5. Organize the coaching of the service providers by the CDV Agencies, to better apply the PBF instruments such as the business plans and the indices management tool.
6. Offer PBF contracts to private sector health facilities that fulfill minimum standards and have the potential to provide high quality services.
7. Renew the health facility contracts each three months instead of yearly.

Central African Republic – context and recommendations

The PBF reforms have been tested in the Central African Republic since 2009 in three Health Regions implemented by Cordaid. Since 2016, this coverage has been extended with the support of the World Bank. And in 2018, the European Union provided support for the implementation of FBP in three other health regions. These projects cover more than 60% of the Central African population.

International Medical Corps (IMC), as an EU partner, has been implementing a health system strengthening program through PBF in 2 health districts since 2018 in health region 5, and plays the role of ACV. The ​​intervention area of the international NGO IMC is characterized by a very low population density, poor road conditions, and access is mainly by plane.

The analysis of the PBF feasibility score of the project area is 64%, while the minimum score required is 80%. To increase this score the following recommendations are proposed:

1. Advocate for the establishment of a national government PBF support fund (for sustainability).
2. Initiate advocacy with the national PBF Unit and the EU on the need to increase the PBF program budget in the IMC intervention districts to at least $8/inhabitant/year. This due to the very difficult circumstances in these two districts.
3. Advocate that the national Ministry of Health directorates are placed under performance contracts.
4. Place the Contract Development and Verification Agency (CDV) under a PBF performance contract.
5. Separate the functions of the CDV Agency and payment agency.

Explore the possibilities of using mobile money with telephone companies. Explore the recruitment of local “Financial Service Providers” (private commercial) in areas where there is no telephone network coverage. Create/use the (available) bank accounts of local regulators and/or service providers for the payment of subsidies.